CD, or not CD, that is the question: a digital interobserver agreement study in coeliac disease

OBJECTIVE

Coeliac disease (CD) diagnosis generally depends on histological examination of duodenal biopsies. We present the first study analysing the concordance in examination of duodenal biopsies using digitised whole-slide images (WSIs). We further investigate whether the inclusion of immunoglobulin A tissue transglutaminase (IgA tTG) and haemoglobin (Hb) data improves the interobserver agreement of diagnosis.

DESIGN

We undertook a large study of the concordance in histological examination of duodenal biopsies using digitised WSIs in an entirely virtual reporting setting. Our study was organised in two phases: in phase 1, 13 pathologists independently classified 100 duodenal biopsies (40 normal; 40 CD; 20 indeterminate enteropathy) in the absence of any clinical or laboratory data. In phase 2, the same pathologists examined the (re-anonymised) WSIs with the inclusion of IgA tTG and Hb data.

RESULTS

We found the mean probability of two observers agreeing in the absence of additional data to be 0.73 (±0.08) with a corresponding Cohen's kappa of 0.59 (±0.11). We further showed that the inclusion of additional data increased the concordance to 0.80 (±0.06) with a Cohen's kappa coefficient of 0.67 (±0.09).

CONCLUSION

We showed that the addition of serological data significantly improves the quality of CD diagnosis. However, the limited interobserver agreement in CD diagnosis using digitised WSIs, even after the inclusion of IgA tTG and Hb data, indicates the importance of interpreting duodenal biopsy in the appropriate clinical context. It further highlights the unmet need for an objective means of reproducible duodenal biopsy diagnosis, such as the automated analysis of WSIs using artificial intelligence.

Immunosuppressant side effect profile does not differ between organ transplant types

Transplantation has enhanced the quality of life of all transplant recipients, but concern remains regarding the side effects of immunosuppressant drugs. In order to respond to these concerns, a survey to ascertain the side effect profile of transplant recipients was undertaken to identify the impact of chronic immunosuppression on quality of life. A nationwide survey of solid organ transplant recipients was carried out using a newly developed immunosuppressant side effect survey. Kidney, kidney-pancreas, liver and heart recipients responded to the survey (n = 505) and reflect the national distribution based on the UNOS data for organ type, recipient race and gender. The survey had four subscales: emotional burden, life/role responsibilities, mobility and GI distress. A fifth subscale included miscellaneous side effects that are more prevalent during the first 2 years post-transplant. Frequency and severity of each side effect were coded on a scale of 0-4 from 'no problem' to 'always' a problem. The entire range of possible scores (0-160) was reported, reflecting adequate variability in the responses. The sample consisted of 51% males, 77% Caucasians, 15% African Americans, with the remaining 8% other races. There were 225 (44.5%) kidney, 147 (29.1%) liver, 101 (20%) heart and 32 (6.4%) pancreas included. Age ranged from 18-71 years with time since transplant 1-21 years. Overall frequency (12.1 +/- 6.08), severity (10.5 +/- 6.96) and weighted scores (25.4 +/- 19.9) were low suggesting that, as a whole, immunosuppressant side effects, while present, were not severe or troublesome for most patients. Side effect profiles appeared similar among organ types. Differences were detected in the GI distress subscale with the heart recipients reporting significantly less GI distress than liver recipients (13.8 vs. 19.2; P<0.05). Side effect impact on mobility tended to increase between time eras; however, no statistical significance was detected. Side effects are a concern among health-care professionals; however, based on the results of this study, immunosuppressant-related side effects are not detrimental to quality of life and show no differences between types of organ transplanted.

Sustained improvements in cardiac geometry and function following kidney-pancreas transplantation

Kidney-pancreas (KP) transplantation has been shown to improve left ventricular (LV) geometry and function 6-24 months after the procedure, yet whether these improvements are sustained in long-term survivors has not been demonstrated. This study examined whether early improvements in LV geometry and function were sustained 3-5 years after KP transplantation. Left ventricular function and geometry were prospectively evaluated prior to, and at 1, 2, and 3-5 years posttransplant using two-dimensional, M-mode, echocardiography with Doppler interrogation in the parasternal and apical views. The sample included 21 KP and a comparison group of 12 diabetic kidney-alone (KA) recipients. Long-term (3-5 years) data were obtained for KP recipients only. Although KA recipients had a longer duration of dialysis and worse diastolic function pretransplant, the groups were similar on other baseline measures. KA recipients experienced minimal improvements while KP recipients had significant improvements in cardiac function and geometry, both in terms of mean values and the percentage of KP recipients who experienced normalization posttransplant (p < 0.05). KP recipient improvements were also sustained at 3-5 years posttransplant on three of five measures, with 75% of long-term KP recipients achieving normal LV mass posttransplant compared with 31% pretransplant. Data indicate that significant impairments in cardiac geometry and function occur in diabetic KA and KP recipients. Though both groups experienced early improvements posttransplant, KP recipients achieved more dramatic and clinically significant improvements at 1, 2, and 3-5 years posttransplant. Additional studies are needed to examine the relevance of these findings with regard to the cardiac morbidity and mortality of these patients.

Posttransplant improvement in heart rate variability correlates with improved quality of life

A prospective evaluation of 37 kidney and 20 kidney-pancreas transplant recipients was conducted to assess the relationship between pre- to posttransplant changes in heart rate variability (HRV) and quality of life (QoL). Assessments of 24-hour interbeat variability (pNN50 and rMSSD, SDNN, SDANN) and power spectral analysis of total, low (sympathetic), and high (parasympathetic) frequency components of HRV were performed. The Sickness Impact Profile was used to assess three dimensions of QoL (physical, psychosocial, and total functioning) prior to and at 6 months following transplantation. Changes in vagally mediated time domain measures of HRV were related to changes in physical and total functioning. Stronger correlations occurred between biobehavioral measures in kidney-pancreas recipients, with the strongest relationships occurring between changes in HRV frequency domain measures and changes in physical functioning. Findings indicate that changes in HRV and QoL are related, suggesting that interventions that enhance transplant recipients' HRV may also enhance their QoL.

Subjective burden in young and older African-American caregivers of patients with end stage renal disease awaiting transplant

The purposes of this study were to identify the level of subjective burden reported by African American caregivers of patients diagnosed with end stage renal disease (ESRD) awaiting transplantation and identify whether subjective burden, personal strain, and role strain varied by caregiver age. An exploratory descriptive survey design was used. The convenience sample consisted of 78 African American family caregivers. Subjects were obtained from a University transplant clinic in the Mid-South. Caregivers completed the 22-item self-administered Burden Interview (BI) and a demographic data form. Data were analyzed using descriptive statistics and the appropriate parametric and nonparametric tests of group differences. Most caregivers, reported little to none or mild to moderate burden. Results also indicated that there was no significant difference in the level of overall burden, personal strain, and role strain reported by young and older caregivers. Additional findings revealed that burden was least in the caregivers of patients who independently performed activities of daily living (ADL) and greatest among the caregivers of patients assisted by someone other than the caregiver with ADL. Findings from this study may help nurses to assist caregivers to identify their level of burden early in the caregiving process. Implementation of early interventions may prevent negative psychological and physical outcomes in these caregivers.

Impact of a human interest video on living-donor kidney donation rates

Forty-five potential living donors participated in this study to see if a human interest video featuring living donors and recipients who had been through the transplant process would increase living-donor donation rates and knowledge about living-donor organ donation. While neither donation rates nor knowledge achieved statistical significance, the data clearly demonstrated a clinically significant (clinically relevant) increase in donation rates.

Effectiveness of a cardiovascular health promotion education intervention on the attitudes of urban African American school-age children

African American children are at risk for high rates of morbidity and mortality associated with cardiovascular (CV) disease as they become adults, yet little is known about the effectiveness of CV risk-reduction interventions in African American children. This study explored the effectiveness of a concentrated CV health promotion educational program on health-related attitudes of 76 African American children enrolled in a mid-southern school system. The Children's Cardiovascular Health Promotion Attitude Scale was used to examine differences in attitude prior to and 2 weeks following a focused health education intervention. Results demonstrate that children have preconceived attitudes regarding practice of health behaviors and that these attitudes are modifiable with age and developmental level specific educational interventions. Findings indicate the need for health care providers to assume more active roles in reducing the risk of future CV disease and death in African Americans through health promotion education of individuals who influence the development of children's attitudes.

Racial and gender differences in quality of life following kidney transplantation

PURPOSE

To determine if race or gender affected changes in quality of life (QoL) reported by nondiabetic kidney transplant recipients from pre- to 6 and 12 months post-transplant and offer possible explanations. Information gained may offer direction for interventions designed to enhance post-transplant QoL for patients who may be less likely to attain improved outcomes.

DESIGN

Descriptive, prospective clinical study. A convenience sample of 90 male and female Caucasian-American and African-American patients was used. Patients were 19 to 67 years of age, nondiabetic, and undergoing kidney transplantation at one university hospital located in the southern United States. Data were collected 1990 to 1995.

METHODS

Three questionnaires measuring QoL were used: the Sickness Impact Profile, Ferrans and Powers' Quality of Life Index, and the Adult Self-Image Scales. Patients completed questionnaires at the time of transplant and at their routine 6- and 12-month post-transplant evaluation visits. Repeated measures analysis of variance with multiple pre-planned comparisons of least-squares (LS) means were performed to determine if differences existed between and within study groups over time.

FINDINGS

African-Americans achieved less improvement than Caucasian-Americans in affective as well as functional measures of QoL. Women scored consistently lower than men on most QoL measures at baseline and reported greater improvement in functional ability while perceptions of self-image remained low.

CONCLUSIONS

Although transplantation dramatically improves QoL, some segments of the patient population, namely African-Americans and women, do not benefit to the same extent as others. Nurses need to recognize sociocultural differences in patients and how these differences affect care requirements.

Family caregivers' burden, quality of life, and health following patients' renal transplantation

Improved quality of life and physical functioning among renal transplant recipients have been documented; however, little of the literature has addressed the effects of transplantation on family caregivers. The purpose of this exploratory descriptive study was to characterize the level of subjective burden, quality of life, and self-rated health of caregivers who assist family members prior to transplantation as well as at 6 months following. The study sample included 19 caregivers of 19 renal transplant recipients. In general, caregiver burden, quality of life, and self-rated health did not improve following patients' transplants. In addition, 9 of 19 family caregivers reported increased burden. Because much of healthcare is family-based and greater reliance on family support seems inevitable, further studies are needed to examine the impact of transplantation on the family as well as the impact of the family on patients' posttransplant outcomes.

Autonomic dysregulation in patients awaiting kidney transplantation

Sudden cardiac death occurring in patients with end-stage renal disease (ESRD) may be related to poor autonomic function (AF). It is not known whether patients having a sudden death can be identified by commonly used AF evoked tests or if a newer test evaluating heart rate variability (HRV) with power spectral analysis can better distinguish at-risk patients. This study sought to characterize AF in patients awaiting kidney transplantation, to identify factors associated with poor AF and sudden death, and to compare evoked versus 24-hour measures of cardiac AF. All patients underwent evoked cardiac AF tests, which included changes in heart rate with deep breathing (deltaBPM) and valsalva (VR). In addition, 24-hour HRV was assessed with time domain measurements of interbeat variability (pNN50, SDANN, and SDNN), which are associated with vagal function, circadian function, and sudden cardiac death (SDNN < 50), respectively. Frequency domain measures obtained by power spectral analysis (total, low, and high hertz) quantify total neural, sympathetic, and parasympathetic activity of the heart, respectively. Data were collected on 184 nondiabetic patients, 60 type 1 diabetic patients, and 34 type 2 diabetic patients with ESRD referred for transplantation. Five patients, all receiving peritoneal dialysis, experienced nontraumatic sudden cardiac death during the study. Evoked and 24-hour HRV control data were obtained from 67 and 48 healthy adults, respectively. Data show that regardless of subgroup, there was significant AF dysregulation in the 278 patients with ESRD, particularly for those with diabetes and those receiving peritoneal dialysis. Frequency domain measurements (three in each group: nondiabetic patients, type 1 diabetic patients, type 2 diabetic patients, deceased patients, hemodialysis patients, peritoneal dialysis, and nondialysis patients [n = 21]) were most sensitive to dysregulation, with 16 of 21 (76%) measurements more than 2 SD from the mean of the control group. This is in contrast to the time domain measurements (one of 21 [0.04%] > 2 SD from the mean of the control group) and evoked measurements (eight of 14 [57%] outside of the established norms). Of the five deceased patients, only one displayed normal values for all eight AF measurements reported; three (60%) had SDNNs less than 50. Of the 248 surviving patients, 42 (17%) had an SDNN less than 50. When analyzed, the ability of the SDNN to identify an at-risk group was found to have a sensitivity of 60%, a specificity of 83%, a positive predictive value of 7%, a negative predictive value of 99%, and an accuracy of 83%. While AF and time on dialysis were not found to be correlated, the length of diabetes was inversely related to all AF measures (r = -0.27 to -0.48; P < 0.0001), except pNN50. These data suggest that all groups of ESRD patients have severely compromised AF and, regardless of the type of diabetes, those with diabetes have the greatest degree of dysregulation. In addition, individuals receiving peritoneal dialysis were more prone to dysregulation, and the SDNN, a time domain measurement of 24-hour HRV, holds the promise of identifying patients at increased risk for early death in this population.

Post kidney transplant quality of life prediction models

Quality of life (QoL) is generally found to improve for renal transplant recipients, although some patients continue to experience health-related problems. It was within this context that we undertook our investigation which focused on identifying the factors predictive of QoL following kidney transplantation.

METHODS

The sample included 91 non-diabetic patients of which 69 provided 6-month data and 68 provided 12-month data. Three QoL questionnaires were administered to capture as many QoL dimensions as possible. Repeated measure analyses of variance with multiple post hoc comparisons of LS means was conducted to determine how QoL outcomes differed over time. Correlational analyses were performed on the 12-month dataset to determine which variables to include in the modeling process. Multiple stepwise regression with forward and backward entry were used in the prediction modeling.

RESULTS

Essentially all patients experienced a significant improvement in QoL and the improvement occurred early and appeared to be sustained. Five separate prediction models were constructed, each including number of hospital days in first 6 months, employment, and social support.

CONCLUSIONS

The similarity of the five models is of note. It is not necessarily these specific variables per se that predict QoL outcomes, but rather what they conceptually represent. These findings provide direction for interventions designed to enhance post-transplant QoL.

Cardiovascular dysautonomia of patients with end-stage renal disease and type I or type II diabetes

BACKGROUND

End-stage renal disease and diabetes mellitus are known to cause autonomic dysfunctions that are responsible for poor outcomes. Studies suggest that 24-hour heart rate variability with power spectral analysis is more sensitive to early changes in autonomic function than laboratory-evoked measures.

OBJECTIVES

To evaluate cardiovascular autonomic function in patients (a) awaiting kidney or pancreas-kidney transplantation, (b) without diabetes (NonDM), (c) with Type I insulin dependent diabetes mellitus (IDDM), and (d) with Type II noninsulin dependent diabetes mellitus (NIDDM), and to compare the results of the laboratory-evoked cardiovascular autonomic tests with those from 24-hour heart rate variability monitoring with power spectral analysis.

METHOD

This cross-sectional study examined autonomic function in prekidney transplant patients with and without diabetes (N=96), comparing laboratory-evoked measures to 24-hour measures.

RESULTS

The nondiabetic group had a normal change in heart rate with deep breathing, Valsalva ratio, and change in systolic blood pressure with tilt. Both diabetic groups had poorer values for all measures of heart rate variability; demonstrated abnormal changes in heart rate with deep breathing and borderline Valsalva ratios; demonstrated a greater decrease in circadian rhythmicity; and had lower SDNNS, pNN50s, and rMSSDs than the nondiabetic group.

CONCLUSIONS

Results showed that 24-hour measures are more sensitive, that patients with end-stage renal disease and diabetes regardless of type experience significantly poorer function than do patients without diabetes, and that these values approach those associated with sudden cardiac death.

Subjective burden and quality of life in family caregivers of patients with end stage renal disease

OBJECTIVE

The purpose of this study was to determine the quality of life (QoL) and level of subjective burden reported by family caregivers of persons with ESRD and to examine the relationship between these variables. The influence of patient (gender), illness (dialysis and diabetes status), and caregiver (race, gender, employment status, relationship to patient, and self-rated health) factors on burden and QoL was also examined.

DESIGN

An exploratory descriptive design was used.

SAMPLE

The convenience sample consisted of 96 caregivers of 96 transplant candidates diagnosed with end-stage renal disease. Participants were recruited from a University transplant service located in the Mid-South.

METHODS

Caregivers of patients attending pretransplant clinic evaluations were invited to participate in the study. Caregivers completed a demographic data form, the Caregiver Burden Interview, and General QoL measure. Patient demographic data and dialysis and diabetes status were retrieved from the patient health history database of an ongoing study conducted by our transplant research team. Data were analyzed using descriptive statistics, Spearman's correlation analysis, and the appropriate parametric and nonparametric tests of group differences.

RESULTS

Caregivers, most of whom were women, reported good QoL and little to no burden. Caregiver QoL was significantly related to caregiver burden and caregiver self-rated health. Neither caregiver race, gender, relationship to the patient, nor patient gender significantly contributed to caregiver burden or caregiver QoL. Caregiver burden did not differ by dialysis type (CAPD, incenter hemodialysis, etc.) or employment category (full-time, part-time, etc.), however QoL differed by employment status.

CONCLUSIONS

Findings document the linkages among burden, QoL, and self-rated health as well as illness factors, such as diabetes status. Knowledge about these relationships may facilitate the development of interventions that enhance patient and family outcomes.

Quality of life outcomes associated with variable posttransplant prednisone dosing regimens

Prednisone tapering has become more common in the management of transplant recipients. Benefits of this practice, however, must be weighed against the risks. This study identified outcomes associated with variable low dose prednisone protocols. The study sample included 98 kidney and kidney-pancreas transplant recipients 1 year after transplant. Graft function, side effects of steroid therapy, and quality of life were recorded on patients receiving 0 (n = 5), 1 to 5 (n = 4), 5 to 7.5 (n = 5), 7.5 to 10 (n = 21), and greater than 10 mg/d prednisone (n = 63). Despite the fact that patients were assigned to the low dose groups because they were at risk for or already experiencing steroid induced side effects, the low dose groups presented side effect and quality of life profiles similar to or better than those of the standard dose group.